Lowering high LDL cholesterol remains one of the most important ways to prevent heart attacks and strokes, according to heart experts.
In a new editorial, doctors argue that many people at high risk may benefit from starting treatment with powerful cholesterol-lowering medicines rather than waiting for lifestyle changes alone to work.
LDL is often called “bad” cholesterol. The body needs cholesterol for normal functions, but too much LDL can become trapped in artery walls and contribute to fatty deposits known as plaque.
Over time, these deposits can narrow the arteries and reduce blood flow. If a plaque breaks open and causes a blood clot, it can trigger a heart attack or stroke.
Experts from Florida Atlantic University’s Schmidt College of Medicine say strong statins should play a central role in preventing these problems. Their editorial was published in the medical journal Trends in Cardiovascular Medicine.
Statins are medicines that lower the amount of cholesterol made by the liver. They can significantly reduce LDL levels and have been studied for decades in large clinical trials involving people at risk of heart disease.
The authors particularly highlight atorvastatin and rosuvastatin, two widely used and powerful statins. For patients who need major reductions in LDL, they argue that doctors should consider starting with a high-intensity dose and lowering it later if side effects or other concerns develop.
One reason is that patients often remain on the dose they were first prescribed. Starting with a dose that lowers LDL strongly may therefore help more patients reach recommended cholesterol levels.
Medication does not replace healthy living. The researchers stress that people should avoid smoking, exercise regularly, maintain a healthy weight, control blood pressure, eat a heart-healthy diet and avoid excessive alcohol.
But lifestyle changes can be difficult to maintain and may not lower cholesterol enough in people who already have a high risk of heart disease. The authors point to the large number of American adults with metabolic syndrome, a combination of health problems that can include high blood pressure, high blood sugar, unhealthy cholesterol levels and excess fat around the waist.
Physical activity is another major concern. Many adults do not get the recommended amount of exercise, although even modest increases in movement can benefit the heart and blood vessels.
Age should not be viewed as a reason to give up on exercise. Older adults can still improve their health by becoming more active, although people with medical conditions may need advice about what type and amount of exercise is appropriate.
For some patients, statins alone may not lower LDL enough. Doctors can add other cholesterol medicines, such as ezetimibe, which reduces cholesterol absorption in the intestine, or newer injectable drugs that can produce very large reductions in LDL.
These additional medicines can be especially useful for people at very high risk or those with inherited forms of extremely high cholesterol. However, treatment decisions depend on a person’s overall risk, cholesterol level, other medical conditions and ability to tolerate medicines.
The editorial also discusses aspirin. For people who have already had a heart attack, stroke or certain other cardiovascular problems, aspirin may be recommended along with cholesterol treatment because it helps reduce the formation of dangerous blood clots.
For people who have never had cardiovascular disease, the decision is more complicated. Aspirin can cause serious bleeding, so doctors must weigh the possible heart benefits against that risk rather than recommending it routinely to everyone.
Omega-3 products have also received attention for heart protection, but the evidence is mixed. Many fish-oil supplements have not shown additional cardiovascular benefits for people already receiving modern treatments such as statins.
One prescription form, icosapent ethyl, produced different results in the REDUCE-IT clinical trial. In selected high-risk patients with elevated blood fats who were already taking statins, it reduced the risk of major cardiovascular events.
The editorial’s senior author, Dr. Charles Hennekens, and his colleagues emphasize that preventing cardiovascular disease before a heart attack or stroke occurs can save lives. Their message is that healthy habits and proven cholesterol-lowering medicines should be used together when a person’s level of risk makes treatment appropriate.
Anyone concerned about high LDL should discuss treatment with a health professional rather than changing a statin dose or starting aspirin or supplements independently. The best approach depends on a person’s cholesterol numbers, medical history, age, medications and overall risk of heart disease.
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